Diagnosis and treatment of neuropathy
Recommendations
| Identify and Treat the Cause | ||
|---|---|---|
| 1 | Conduct a foot inspection and examine for decreased sensation. Correct (if possible) risk factors for ulcer formation/amputation:  Vascular supply  Infection  Pressure (including bony deformity) Remember the mnemonic VIP | Level of Evidence Not Assessed |
| 2 | Perform neurologic testing, even in patients with no symptoms, to diagnose or rule out diabetic neuropathy. | Level of Evidence Not Assessed |
| 3 | Identify risk of foot ulceration based on results of neurologic testing, including increased vibration threshold and inability to feel pressure of a 10-g monofilament. | Level of Evidence Not Assessed |
| Address Patient-centered Concerns | ||
|---|---|---|
| 4 | Provide individualized education about plantar pressure redistribution/daily foot inspection. | Level of Evidence Not Assessed |
| 5 | Assess neuropathic pain and treat when required. | Level of Evidence Not Assessed |
| Provide Local Wound Care | ||
|---|---|---|
| 6 | Follow recommended strategies to maintain a healthy foot in all patients with diabetic neuropathy. | Level of Evidence Not Assessed |
| Provide Organizational Support | ||
|---|---|---|
| 7 | Establish and empower an interprofessional team to work with Persons With Diabetes (PWD) and neuropathy. | Level of Evidence Not Assessed |
Background
The definition of diabetic neuropathy used for this summary is the following:• The presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes, after exclusion of other causes.
Sensory neuropathy, present in 30 to 50% of people with diabetes, is the most important common cause of foot ulceration, and 45 to 60% of ulcerations are entirely neuropathic in origin. Motor and autonomic neuropathy may also contribute to the risk of ulceration. Distal symmetric sensorimotor neuropathy is the most common clinical presentation.
Presenting symptoms vary and may include various types of pain, altered temperature perception, paresthesia, hyperesthesia, allodynia or insensitivity. Nocturnal exacerbation may be present. Motor symptoms, such as weakness, may also be present. Some patients report no symptoms.
Neuropathy cannot be excluded without a neurologic examination. Various scoring measures exist, including the Neuropathy Disability Score and the Michigan Neuropathy Screening Instrument. The ankle reflex is often reduced or absent in people with diabetic neuropathy. Absent ankle reflexes are a useful predictor of ulceration risk. [SHOULD WE ADD IN 10-POINT TESTING OR OTHER DETAIL?]
Electrophysiologic testing is the most sensitive, reproducible and reliable method of evaluating nerve function, and such testing can also detect subclinical neuropathy. Electrophysiology does not diagnose the cause of the neuropathy.
Vibration perception threshold can be evaluated using a tuning fork (128Hz) or a biothesiometer, which can quantify and measure progressive sensory loss. A decreased vibration threshold is highly predictive of foot ulceration, with a threshold above 25V increasing risk tenfold compared with lower thresholds.
Semmes Weinstein monofilaments can identify loss of pressure sense. Absent protective threshold is diagnosed if an individual cannot feel at least seven of 10 tested pedal sides. A sensitive predictor of ulceration and amputation risk is inability to feel pressure of a 10-g monofilament.
Treatment of neuropathy is focused on maintaining a healthy foot and preventing ulceration. Treatment measures include management of any foot deformities, appropriate footwear, frequent professional monitoring and patient education about the importance of proper foot care and footwear and effective diabetes management.
References
| Essential Publications |
|---|
| 1 | Screening for diabetic peripheral neuropathy |
Quality Indicator
|
Type: Validation study |
| Perkins BA, Olaleye D, Zinman B, Bril V. Simple Screening Tests for Peripheral Neuropathy in the Diabetes Clinic. Diabetes Care2001;24(2):250-256. | |||
| The diagnostic properties of the Semmes-Weinstein monofilament examination (SWME), superficial pain sensation, vibration testing (on-off method), and vibration testing (timed method) were determined by comparison with the reference standard of electrophysiological tests for the diagnosis of peripheral neuropathy. The likelihood ratio for an abnormal test for each of the screening tests indicates that all tests are useful in detecting peripheral neuropathy: vibration (on-off method) 26.6, vibration (timed) 18.5, monofilament 10.2, superficial pain 9.2. The combination of two tests did not improve diagnosis. | |||
| 2 | Walking for people with diabetic peripheral neuropathy |
Quality Indicator
|
Type: Correlation study |
| Kanade RV, van Deursen M, Harding K, Price P. Walking performance in people with diabetic neuropathy: benefits and threats. Diabetologia 2006;49:1747-1754. | |||
| In this study, total heart beat index, gait velocity, and average daily strides were determined in several patient groups: those with diabetic neuropathy, with diabetic foot ulcers, with partial foot amputations, and with trans-tibial amputations. In patients with more foot complications, total heart beat index increased, and gait velocity and daily stride count decreased. It was concluded that walking should be recommended only with protective footwear. | |||
| 3 | Recombinant human platelet-derived growth factor |
Quality Indicator
|
Type: Cohort study (2 groups) |
| Margolis DJ, Bartus C, Hoffstad O, Malay S, Berlin JA. Effectiveness of recombinant human platelet-derived growth factor for the treatment of diabetic neuropathic foot ulcers. Wound Repair Regen. 2005 Nov-Dec;13(6):531-6. | |||
| The purpose of this study is to evaluate the effectiveness of recombinant human platelet-derived growth factor (rhPDGF) in the treatment of diabetic neuropathic foot ulcers. 24,898 individuals were included, of whom 9.6% received treatment with rhPDGF. The results showed that rhPDGF is effective in both promoting healing of diabetic foot ulcers and in preventing lower-extremity amputations, compared to standard therapy. | |||
| 4 | Recombinant human platelet-derived growth factor |
Quality Indicator
|
Type: RCT |
| Steed DL. Clinical evaluation of recombinant human platelet-derived growth factor for the treatment of lower extremity ulcers. Plast Reconstr Surg. 2006 Jun;117(7 Suppl):143S-149S; discussion 150S-151S. | |||
| This study compares recombinant human platelet-derived growth factor and a placebo in the treatment of chronic neuropathic diabetic foot ulcers. The results show that the recombinant human platelet-derived growth factor increases healing rate and decreases time to complete healing. Adverse effects and ulcer recurrence were similar for both groups. This shows that recombinant human platelet-derived growth factor is an effective treatment strategy for diabetic foot ulcers and can be used clinically. | |||
| 5 | Graftskin in the treatment of Diabetic Foot Ulcers |
Quality Indicator
|
Type: RCT |
| Veves A, Falanga V, Armstrong DG, Sabolinski ML; Apligraf Diabetic Foot Ulcer Study. Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. Diabetes Care. 2001 Feb;24(2):290-5. | |||
| This study examined the effect of graftskin on the healing of noninfected nonischemic chronic plantar diabetic foot ulcers. The results showed that graftskin facilitated improved healing than other current therapies, with no associated side-effects. Consequently, graftskin can be used clinically as an adjunctive therapy for diabetic foot ulcers. | |||